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Assess urgent care (UC) clinician prescribing practices and factors associated with first-line antibiotic selection and recommended duration of therapy for sinusitis, acute otitis media (AOM), and pharyngitis.
Retrospective cohort study.
All respiratory UC encounters and clinicians in the Intermountain Health (IH) network, July 1st, 2019–June 30th, 2020.
Descriptive statistics were used to characterize first-line antibiotic selection rates and the duration of antibiotic prescriptions during pharyngitis, sinusitis, and AOM UC encounters. Patient and clinician characteristics were evaluated. System-specific guidelines recommended 5–10 days of penicillin, amoxicillin, or amoxicillin-clavulanate as first-line. Alternative therapies were recommended for penicillin allergy. Generalized estimating equation modeling was used to assess predictors of first-line antibiotic selection, prescription duration, and first-line antibiotic prescriptions for an appropriate duration.
Among encounters in which an antibiotic was prescribed, the rate of first-line antibiotic selection was 75%, the recommended duration was 70%, and the rate of first-line antibiotic selection for the recommended duration was 53%. AOM was associated with the highest rate of first-line prescriptions (83%); sinusitis the lowest (69%). Pharyngitis was associated with the highest rate of prescriptions for the recommended duration (91%); AOM the lowest (51%). Penicillin allergy was the strongest predictor of non–first-line selection (OR = 0.02, 95% CI [0.02, 0.02]) and was also associated with extended duration prescriptions (OR = 0.87 [0.80, 0.95]).
First-line antibiotic selection and duration for respiratory UC encounters varied by diagnosis and patient characteristics. These areas can serve as a focus for ongoing stewardship efforts.
We compared antibiotic prescribing rates for respiratory conditions in a national sample of outpatient visits from 2010 to 2018 between physicians and advanced practice clinicians (APCs). APCs prescribed antibiotics more frequently than physicians (58% vs 52%), but there were no differences in selection of guideline recommended first-line agents between specialties.
To characterize antifungal prescribing patterns, including the indication for antifungal use, in hospitalized children across the United States.
We analyzed antifungal prescribing data from 32 hospitals that participated in the SHARPS Antibiotic Resistance, Prescribing, and Efficacy among Children (SHARPEC) study, a cross-sectional point-prevalence survey conducted between June 2016 and December 2017.
Inpatients aged <18 years with an active systemic antifungal order were included in the analysis. We classified antifungal prescribing by indication (ie, prophylaxis, empiric, targeted), and we compared the proportion of patients in each category based on patient and antifungal characteristics.
Among 34,927 surveyed patients, 2,095 (6%) received at least 1 systemic antifungal and there were 2,207 antifungal prescriptions. Most patients had an underlying oncology or bone marrow transplant diagnosis (57%) or were premature (13%). The most prescribed antifungal was fluconazole (48%) and the most common indication for antifungal use was prophylaxis (64%). Of 2,095 patients receiving antifungals, 79 (4%) were prescribed >1 antifungal, most often as targeted therapy (48%). The antifungal prescribing rate ranged from 13.6 to 131.2 antifungals per 1,000 patients across hospitals (P < .001).
Most antifungal use in hospitalized children was for prophylaxis, and the rate of antifungal prescribing varied significantly across hospitals. Potential targets for antifungal stewardship efforts include high-risk, high-utilization populations, such as oncology and bone marrow transplant patients, and specific patterns of utilization, including prophylactic and combination antifungal therapy.
Healthcare disparities and inequities exist in a variety of environments and manifest in diagnostic and therapeutic measures. In this commentary, we highlight our experience examining our organization’s urgent care respiratory encounter antibiotic prescribing practices. We identified differences in prescribing based on several individual characteristics including patient age, race, ethnicity, preferred language, and patient and/or clinician gender. Our approach can serve as an electronic health record (EHR)–based methodology for disparity and inequity audits in other systems and for other conditions.
Pediatric antimicrobial stewardship programs (ASPs) improve antibiotic use for hospitalized children. Prescriber surveys indicate acceptance of ASPs, but data on infectious diseases (ID) physician opinions of ASPs are lacking. We conducted a survey of pediatric ID physicians, ASP and non-ASP, and their perceptions of ASP practices and outcomes.
To assess association of pharmacist gender with acceptance of antibiotic stewardship recommendations.
A retrospective evaluation of the Reducing Overuse of Antibiotics at Discharge (ROAD) Home intervention.
The study was conducted from May to October 2019 in a single academic medical center.
The study included patients receiving antibiotics on a hospitalist service who were nearing discharge.
During the intervention, clinical pharmacists (none who had specialist postgraduate infectious disease residency training) reviewed patients on antibiotics and led an antibiotic timeout (ie, structured conversation) prior to discharge to improve discharge antibiotic prescribing. We assessed the association of pharmacist gender with acceptance of timeout recommendations by hospitalists using logistic regression controlling for patient characteristics.
Over 6 months, pharmacists conducted 295 timeouts: 158 timeouts (53.6%) were conducted by 12 women, 137 (46.4%) were conducted by 8 men. Pharmacists recommended an antibiotic change in 82 timeouts (27.8%), of which 51 (62.2%) were accepted. Compared to male pharmacists, female pharmacists were less likely to recommend a discharge antibiotic change: 30 (19.0%) of 158 versus 52 (38.0%) of 137 (P < .001). Female pharmacists were also less likely to have a recommendation accepted: 10 (33.3%) of 30 versus 41 (8.8%) of 52 (P < .001). Thus, timeouts conducted by female versus male pharmacists were less likely to result in an antibiotic change: 10 (6.3%) of 158 versus 41 (29.9%) of 137 (P < .001). After adjustments, pharmacist gender remained significantly associated with whether recommended changes were accepted (adjusted odds ratio [aOR], 0.10; 95%confidence interval [CI], 0.03–0.36 for female versus male pharmacists).
Antibiotic stewardship recommendations made by female clinical pharmacists were less likely to be accepted by hospitalists. Gender bias may play a role in the acceptance of clinical pharmacist recommendations, which could affect patient care and outcomes.
Background: Pharyngitis is 1 of the most common conditions leading to inappropriate antibiotic prescriptions. When personal protective equipment (PPE) was at first constrained during the COVID-19 pandemic, Intermountain Healthcare recommended limiting rapid group A streptococcal pharyngitis (GAS) testing in urgent-care clinics to preserve PPE. Notably, the percentage of pharyngitis encounters prescribed an antibiotic and that underwent GAS testing is a key Healthcare Effectiveness Data and Information Set (HEDIS) measure. We have described our experience with urgent-care pharyngitis encounters and the impact of temporarily reducing GAS testing on antibiotic prescribing before and during the COVID19 pandemic. Method: We identified all urgent care encounters between July 2018 and August 2021 associated with a primary diagnosis of pharyngitis using ICD-10 CM codes and a validated methodology. Pharyngitis encounters were assessed for antibiotic prescriptions ordered through the electronic health record (EHR) and the use of point-of-care rapid GAS tests. Pharyngitis encounters were analyzed monthly. We assessed the percentage of encounters associated with an antibiotic prescription regardless of testing and the percentage of encounters associated with an antibiotic prescription when a GAS test was or was not performed. We examined 3 periods relating to COVID-19 and GAS testing recommendations: the prepandemic period (July 2018–March 2020), the pandemic onset period (April 2020–June 2020), and the pandemic period (July 2020–August 2021). Results: Prior to the pandemic, the monthly percentage of pharyngitis encounters for which rapid GAS testing was performed was nearly 90% (Fig. 1). The average monthly percentage of urgent-care pharyngitis encounters prescribed an antibiotic was 38.9%, and the average percentage of monthly pharyngitis encounters prescribed an antibiotic that also underwent GAS testing was 90.4%. This HEDIS measure declined from 90.4% during the prepandemic period to 29.8% in the pandemic onset period when GAS testing was limited. Following resumption of routine testing practices the monthly percentage of urgent-care pharyngitis encounters for which rapid GAS testing was performed returned to levels ≥80% by July 2020 (Fig. 1). The average percentage of monthly pharyngitis encounters prescribed an antibiotic that also underwent GAS testing rose to 87.3% during this period. Conclusions: Limited PPE in our urgent care centers during the initial months of the COVID-19 pandemic was associated with a mandated substantial decline in rapid GAS testing. As testing volume decreased, we noted a simultaneous relative increase of >30% in antibiotic prescribing for pharyngitis. These findings suggest that rapid streptococcal testing promotes appropriate antibiotic prescribing.
Background: Antibiotics are frequently prescribed–and overprescribed–at hospital discharge, leading to adverse-events and patient harm. Our understanding of how to optimize prescribing at discharge is limited. Recently, we published the ROAD (Reducing Overuse of Antibiotics at Discharge) Home Framework, which identified potential strategies to improve antibiotic prescribing at discharge across 3 tiers: Tier 1–Critical infrastructure, Tier 2–Broad inpatient interventions, Tier 3–Discharge-specific strategies. Here, we used the ROAD Home Framework to assess the association of stewardship strategies with antibiotic overuse at discharge and to describe pathways toward improved discharge prescribing. Methods: In fall 2019, we surveyed 39 Michigan hospitals on their antibiotic stewardship strategies. For patients hospitalized at participating hospitals July 1, 2017, through July 30, 2019, and treated for community-acquired pneumonia (CAP) and urinary tract infection (UTI), we assessed the association of reported strategies with days of antibiotic overuse at discharge. Days of antibiotic overuse at discharge were defined based on national guidelines and included unnecessary therapy, excess duration, and suboptimal fluoroquinolone use. We evaluated the association of stewardship strategies with days of discharge antibiotic overuse 2 ways: (1) all stewardship strategies were assumed to have equal weight, and (2) strategies weighted using the ROAD Home Framework with tier 3 (discharge-specific) strategies had the highest weight. Results: Overall, 39 hospitals with 20,444 patients (56.5% CAP; 43.5% UTI) were included. The survey response rate was 100% (39 of 39). Hospitals reported a median of 12 (IQR, 9–14) of 33 possible stewardship strategies (Fig. 1). On bivariable analyses, review of antibiotics prior to discharge was the only strategy consistently associated with lower antibiotic overuse at discharge (aIRR, 0.543; 95% CI, 0.335–0.878). On multivariable analysis, weighting by ROAD Home tier predicted antibiotic overuse at discharge for both CAP and UTI. For diseases combined, having more weighted strategies was associated with lower antibiotic overuse at discharge (aIRR per weighted intervention, 0.957; 95% CI, 0.927–0.987). Discharge-specific stewardship strategies were associated with a 12.4% relative decrease in antibiotic overuse days at discharge. Based on these findings, 3 pathways emerged to improve antibiotic use at discharge (Fig. 2): inpatient-focused strategies, “doing it all,” and discharge-focused strategies. Conclusions: The more stewardship strategies reported, the lower a hospitals’ antibiotic overuse at discharge. However, different pathways to improve discharge antibiotic use exist. Thus, discharge stewardship strategies should be tailored. Specifically, hospitals with limited stewardship resources and infrastructure should consider implementing a discharge-specific strategy straightaway. In contrast, hospitals that already have substantial inpatient infrastructure may benefit from proactively incorporating discharge into their existing strategies.
Background: Clinical pharmacists are a critical part of antibiotic stewardship. Stewardship often relies on relationships and persuasion, which may be affected by gender bias. Thus, we aimed to assess the association of sex with the acceptance of antibiotic stewardship recommendations. Methods: Between May and October 2019, medicine pharmacists at single hospital reviewed patients on antibiotics and–when a discharge was anticipated–led an antibiotic discussion (or “timeout”) prior to discharge. To explore differences in antibiotic timeout effectiveness by gender, we assessed the association of pharmacist sex with suggestion and acceptance of antibiotic changes using logistic regression controlling for patient characteristics. We also assessed whether hospitalist sex was associated with or moderated the effect of pharmacist sex on acceptance of timeout recommendations. Results: Between May 1, 2019, and October 31, 2019, pharmacists conducted 295 timeouts (patient characteristics in Fig. 1). Overall, 54% of timeouts were conducted by 12 female pharmacists and the remaining 46% were conducted by 8 male pharmacists. Overall, 82 (29%) of 295 timeouts resulted in a pharmacist recommending an antibiotic change, and male pharmacists were more likely to recommend a change: 52 (38%) of 137 versus 30 (19%) 158 (P Conclusions: In this discharge antibiotic intervention, timeouts conducted by women were less likely to result in an antibiotic change than those conducted by men. The difference in effectiveness resulted both from female pharmacists being less likely to recommend a change and from hospitalists being less likely to accept recommendations from a female pharmacist. These findings suggest that gender bias may play a role acceptance of antibiotic stewardship recommendations, which could affect antibiotic use, pharmacist job satisfaction, and patient outcomes.
Background: Billing data have been used in the outpatient setting to identify targets for antimicrobial stewardship. However, COVID-19 ICD-10 codes are new, and the validity of using COVID-19 ICD-10 codes to accurately identify COVID-19 encounters is unknown. We investigated COVID-19 ICD-10 utilization in our urgent care clinics during the pandemic and the impact of using different COVID-19 encounter definitions on antibiotic prescribing rates (APRs). Methods: We included all telemedicine and office visits at 2 academic urgent-care clinics from January 2020 to September 2021. We extracted ICD-10 encounter codes and testing data from the electronic medical record. We compared encounters for which COVID-19 ICD-10 codes were present with encounters for which SARS-CoV-2 nucleic acid amplification testing (NAAT) was performed within 5 days of and up to 2 days after the encounter (Fig. 1). We calculated the sensitivity of the use of COVID-19 ICD-10 codes against a positive NAAT. We calculated the APR as the proportion of encounters in which an antibacterial drug was prescribed. This quality improvement project was deemed non–human-subjects research by the Stanford Panel on Human Subjects in Medical Research.
Background: Emerging evidence supports the use of billing data to identify stewardship targets in primary care. Standardizing an approach to antibiotic prescribing rate (APR) calculations could facilitate external benchmarking. Methods: Using methodology and an ICD-10 dictionary validated in urgent care clinics,1 we created an expanded ICD-10 dictionary to incorporate additional ICD-10 codes from primary care associated with antibiotic prescriptions (Fig. 1). We then compared antibiotic prescribing rates using the urgent care and expanded dictionaries. We included all primary care visits from 2019 to 2020 and extracted ICD-10 codes and antibiotic order data. Using the urgent care and expanded ICD-10 dictionary, we classified each encounter by prescribing tier based on whether antibiotics are almost always (tier 1), sometimes (tier 2), or almost never (tier 3) indicated. For encounters with ICD-10s in multiple tiers, we chose the lowest tier. For multiple ICD-10 codes within the same tier, we chose the first extracted ICD-10 code. We calculated antibiotic prescribing rates as the proportion of encounters associated with ≥ 1 antibacterial prescription. This quality improvement project was deemed non–human subjects research by the Stanford Panel on Human Subjects in Medical Research. Results: The urgent care dictionary has 1,400 ICD-10 codes. We added 1,439 ICD-10 codes derived from primary care encounters to create the expanded ICD-10 dictionary (8.5% tier 1, 9.1% tier 2, and 82.4% tier 3) (Fig. 1). We identified 177,531 encounters; 74% had ≥ 2 associated ICD-10 codes (Fig. 2). In total, 147,085 encounters (82.9%) were classified into a tier using the urgent care dictionary. An additional 22,039 encounters were classified with the expanded dictionary (Table 1). Most added encounters were tier 3 with low 0.7% APR (Tables 1 and 3). In total, 41,473 (28.2%) encounters were classified differently depending on the ICD-10 dictionary used, most commonly changing from tier 3 to tier 2 without an increase in overall tier 2 antibiotic prescribing rate (Tables 2 and 3). Overall antibiotic prescribing rates were similar when using either the urgent care or expanded ICD-10 dictionary (Table 2). Conclusions: The expanded ICD-10 dictionary allowed for classification of more encounters in primary care; however, it did not meaningfully change antibiotic prescribing rates. Antibiotic prescribing rates were likely diluted by classifying more encounters without identifying an associated increase in antibiotic prescribing. A more sophisticated classification system may help to accommodate the diversity and volume of ICD-10 codes used in primary care.
1. Stenehjem E, et al. Clin Infect Dis 2020;70:1781–1787.
We performed a survey of adult infectious diseases (ID) physicians to explore unintended consequences of antimicrobial stewardship programs (ASP). ID physicians worried about disagreement with colleagues, provider autonomy, and remote recommendations. Non-ASP ID physicians expressed more concern regarding ASPs focus on costs, provider efficiency, and unintended consequences of ASP guidance.
To describe acute respiratory illnesses (ARI) visits and antibiotic prescriptions in 2011 and 2018 across outpatient settings to evaluate progress in reducing unnecessary antibiotic prescribing for ARIs.
Setting and patients:
Outpatient medical and pharmacy claims captured in the IBM MarketScan commercial database, a national convenience sample of privately insured individuals aged <65 years.
We calculated the annual number of ARI visits and visits with oral antibiotic prescriptions per 1,000 enrollees overall and by age category, sex, and setting in 2011 and 2018. We compared these and calculated prevalence rate ratios (PRRs). We adapted existing tiered-diagnosis methodology for International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes.
In our study population, there were 829 ARI visits per 1,000 enrollees in 2011 compared with 760 ARI visits per 1,000 enrollees in 2018. In 2011, 39.3% of ARI visits were associated with ≥1 oral antibiotic prescription versus 36.2% in 2018. In 2018 compared with 2011, overall ARI visits decreased 8% (PRR, 0.92; 99.99% confidence interval [CI], 0.92–0.92), whereas visits with antibiotic prescriptions decreased 16% (PRR, 0.84; 99.99% CI, 0.84–0.85). Visits for antibiotic-inappropriate ARIs decreased by 9% (PRR, 0.91; 99.99% CI, 0.91–0.92), and visits with antibiotic prescriptions for these conditions decreased by 32% (PRR, 0.68; 99.99% CI, 0.67–0.68) from 2011 to 2018.
Both the rate of antibiotic prescriptions per 1,000 enrollees and the percentage of visits with antibiotic prescriptions decreased modestly from 2011 to 2018 in our study population. These decreases were greatest for antibiotic-inappropriate ARIs; however, additional reductions in inappropriate antibiotic prescribing are needed.
To assess current resources, interventions, and obstacles of pediatric outpatient antimicrobial stewardship programs (ASP).
Institutions from the Sharing Antimicrobial Reports for Pediatric Stewardship OutPatient collaborative (SHARPS-OP).
Antimicrobial stewardship leaders from the above institutions.
An investigator-developed survey was deployed online in September 2020 to antimicrobial stewardship leaders in SHARPS-OP institutions. The survey was divided into 4 sections: (1) basic information, (2) status of pediatric outpatient ASP in the institutions including financial support, (3) outpatient ASP interventions undertaken by the institutions, and (4) needs and SHARPS-OP collaborative goals.
Of 56 invited institutions, 45 participated, achieving an 80% response rate. Only 5 sites (11%) had allocated financial support for an outpatient ASP, compared to 42 (95.6%) for their inpatient ASP. The most widely used outpatient ASP interventions included antimicrobial guidance (57.8%), education (46.7%), and quality improvement projects (37.8%). Time was identified as the biggest barrier to expanding outpatient ASPs (91.1%), followed by financial support (53.3%), development of meaningful reports (51.1%), and administrative support (44.4%). Important goals of the collaborative included seeking learning opportunities and developing clear metrics for pediatric outpatient ASP benchmarking. Program needs included securing operational support (35.8%) and strengthening data analysis (31.6%).
Very few pediatric institutions with robust inpatient ASPs have devoted time and financial support to advance outpatient efforts. To promote appropriate antibiotic prescribing in the outpatient arena, time and resource funding by administrative leaders are necessary to develop a robust, sustainable stewardship infrastructure.
The Core Elements of Outpatient Antibiotic Stewardship provides a framework to improve antibiotic use, but cost-effectiveness data on implementation of outpatient antibiotic stewardship interventions are limited. We evaluated the cost-effectiveness of Core Element implementation in the outpatient setting.
An economic simulation model from the health-system perspective was developed for patients presenting to outpatient settings with uncomplicated acute respiratory tract infections (ARI). Effectiveness was measured as quality-adjusted life years (QALYs). Cost and utility parameters for antibiotic treatment, adverse drug events (ADEs), and healthcare utilization were obtained from the literature. Probabilities for antibiotic treatment and appropriateness, ADEs, hospitalization, and return ARI visits were estimated from 16,712 and 51,275 patient visits in intervention and control sites during the pre- and post-implementation periods, respectively. Data for materials and labor to perform the stewardship activities were used to estimate intervention cost. We performed a one-way and probabilistic sensitivity analysis (PSA) using 1,000,000 second-order Monte Carlo simulations on input parameters.
The proportion of ARI patient-visits with antibiotics prescribed in intervention sites was lower (62% vs 74%) and appropriate treatment higher (51% vs 41%) after implementation, compared to control sites. The estimated intervention cost over a 2-year period was $133,604 (2018 US dollars). The intervention had lower mean costs ($528 vs $565) and similar mean QALYs (0.869 vs 0.868) per patient compared to usual care. In the PSA, the intervention was dominant in 63% of iterations.
Implementation of the CDC Core Elements in the outpatient setting was a cost-effective strategy.
We surveyed pediatric antimicrobial stewardship program (ASP) site leaders within the Sharing Antimicrobial Reports for Pediatric Stewardship collaborative regarding discharge stewardship practices. Among 67 sites, 13 (19%) reported ASP review of discharge antimicrobial prescriptions. These findings highlight discharge stewardship as a potential opportunity for improvement during the hospital-to-home transition.
Time constraints have been suggested as a potential driver of antibiotic overuse for acute respiratory tract infections. In this cross-sectional analysis of national data from visits to offices and emergency departments, we identified no statistically significant association between antibiotic prescribing and the duration of visits for acute respiratory tract infections.
To develop a pediatric research agenda focused on pediatric healthcare-associated infections and antimicrobial stewardship topics that will yield the highest impact on child health.
The study included 26 geographically diverse adult and pediatric infectious diseases clinicians with expertise in healthcare-associated infection prevention and/or antimicrobial stewardship (topic identification and ranking of priorities), as well as members of the Division of Healthcare Quality and Promotion at the Centers for Disease Control and Prevention (topic identification).
Using a modified Delphi approach, expert recommendations were generated through an iterative process for identifying pediatric research priorities in healthcare associated infection prevention and antimicrobial stewardship. The multistep, 7-month process included a literature review, interactive teleconferences, web-based surveys, and 2 in-person meetings.
A final list of 12 high-priority research topics were generated in the 2 domains. High-priority healthcare-associated infection topics included judicious testing for Clostridioides difficile infection, chlorhexidine (CHG) bathing, measuring and preventing hospital-onset bloodstream infection rates, surgical site infection prevention, surveillance and prevention of multidrug resistant gram-negative rod infections. Antimicrobial stewardship topics included β-lactam allergy de-labeling, judicious use of perioperative antibiotics, intravenous to oral conversion of antimicrobial therapy, developing a patient-level “harm index” for antibiotic exposure, and benchmarking and or peer comparison of antibiotic use for common inpatient conditions.
We identified 6 healthcare-associated infection topics and 6 antimicrobial stewardship topics as potentially high-impact targets for pediatric research.
Antibiotics are not indicated for the treatment of bronchitis and bronchiolitis. Using a nationally representative database from 2006–2015, we found that antibiotics were prescribed in 58% of outpatient visits for bronchitis and bronchiolitis in children, serving as a possible baseline for the expanded HEDIS 2020 measure regarding antibiotic prescribing for bronchitis.